minor“the guidance for PRN medicines was not always clear and some contained conflicting information. We raised this with the registered manager who immediately amended them”
critical“MARs were not always completed when medicines were due to be administered... Some MARs had been signed by staff who, according to rotas supplied, were not scheduled to attend the care visit.”
care planning
1 finding
moderate“Care plans and assessments lacking detail on how staff should support people with daily tasks... care plans did not provide staff with guidance on how to support people in a person-centred way.”
governance
1 finding
critical
“Systems had failed to identify issues with assessing risk, medicines management, staffing and rotas, record keeping and care planning.”
staff training
1 finding
moderate“Not all staff had completed training in areas such as safeguarding adults, moving and handling and Mental Capacity Act (MCA).”
record keeping
1 finding
moderate“Where they had raised concerns in the past, but not a formal complaint, these were not documented.”
staffing levels
1 finding
moderate“Care staff were scheduled to be attending two care calls at the same time, or call visits overlapped.”
consent capacity
1 finding
moderate“Other care files lacked information around people's capacity and whether care related decisions were made in that person's best interests.”
infection control
1 finding
minor“The provider's policy around infection control was not reflective of current government advice and guidelines and was not specific to the type of service the provider was operating.”